John Shepherd speaks with the sports and exercise medicine consultant to gain some clarity on the subject of menstruation

Do coaches discuss the subject of menstruation with their athletes and do athletes know how to deal with their cycles and where they can find out more about retaining optimum health and performance levels? AW spoke with Dr Rebecca Robinson (pictured above after her third place in the 2014 Brighton Marathon) to find out more.

Athletics Weekly: Female athletes are affected by their menstrual cycles but can you tell us in what ways?

Dr Rebecca Robinson: Every female athlete will have a menstrual cycle unique to themselves and its impacts will be individual. We know enough now from research to see some trends. From my work in sport, I see some women for whom the cycle doesn’t have an impact they’re aware of at all, many who find the cycle reassuring that they’re fit and healthy, and some who struggle with heavy or absent periods. At the ends of the age spectrum, being an athletic teen can delay the onset of periods, and after the menopause, some women need support to feel fit and healthy into athletic later life.

AW: Should different types of training be done at different times in the cycle? And does this influence performance?

Dr R: On the first day of bleeding, oestrogen and progesterone hormones are low. Some athletes experience increased muscle soreness due to higher inflammation levels. But muscles adapt well to high intensity at this time and exercise itself can have a beneficial, anti-inflammatory effect.

From the start of a period until ovulation, oestrogen levels rise. Women often find they can train or race hard at this time with more intensity. Just before ovulation, exercise performance may be enhanced. Women have a relatively higher pain threshold at this time too, so this could translate into digging in deep in competition. Around ovulation, the body is under more stress and extra care is needed to ensure recovery and reduce illness risk. A positive energy balance with high carbohydrate intake and adequate sleep is recommended.

After ovulation, the body’s core temperature rises. Blood plasma decreases and relative exercise strain is higher. Moderate efforts are best and it’s important to keep hydrated. A key message is that adaptation to training seems to be better if you have a menstrual cycle than if you don’t. That’s important when it comes to RED-S (relative energy deficiency syndrome – see below).

What is RED-S?

Relative energy deficiency in sport syndrome occurs when athletes are not meeting the energy demands that they need for normal metabolic function plus their sport.

This leads to impaired physiological function of hormones, metabolism, menstrual function, bone health, immunity, protein building, and cardiovascular health amongst other effects.

The consequences of low energy availability shutting off menses on bone health often presents as a stress fracture, and the lack of oestrogen can be a serious risk for osteoporosis (thin and fragile bones).

AW: I have heard that technical work should be avoided at certain times during menstruation and that at other times women may be more prone to benefit from strength work?

Dr R: Hormone changes around the time of a period can affect neuromuscular control – meaning that injuries can be more likely at this time. Just before ovulation, adaptations to strength and high-intensity training are really good. There’s often not a clear-cut right or wrong time to train, but knowing your cycle can certainly be a useful tool when mapping out a training plan.

We do know that athletes suffering from RED-S will have lesser gains from training and lower adaptations. It’s important to highlight that this is the case for men, too, whose testosterone levels can be reduced (see AW’s November 1 issue and Tom Fairbrother’s experiences of the latter).

AW: Are the effects of menstruation different for power and endurance athletes? Many endurance athletes seem to suffer from RED-S whilst power athletes seem to be less affected?

Dr R: Endurance athletics isn’t an aesthetic sport, however, there’s often an emphasis on leanness. Every good coach knows that lighter certainly doesn’t really equal faster beyond a level that is healthy.

However, there can be a tendency for athletes to underfuel, which creates a negative energy balance. That is a real health risk because it can shut off menstrual periods, and this has a detrimental effect on bone health and also on performance, and health in general – and in many ways, from cardiovascular health to mental health.

So, finding the energy balance that’s healthy for you is usually key to performance and getting a regular period is a good marker for this. Of course, it’d be too simple to say this is straightforward for everyone, but if it seems a struggle I would definitely encourage the athlete to seek specialist advice to ensure that their approach is healthy for them.

AW: What should coaches be on the look out for and what do they need to consider?

Dr R: Some athletes can run into problems with RED-S and low energy just because they haven’t got the balance between training and fueling and often a busy life right. Having the conversation about regular menstrual cycles should be important in the coach/athlete relationship, but needs to be done in a healthy, educated, mature way. A great new resource: “health4performance”, can really support athletes, coaches and parents with information and advice. See health4performance.co.uk

Quick wins can be found around nutritional strategies, like fueling directly after training and upping carbohydrate intake, as well as reducing life stress and improving sleep, where possible.

Not all athletes with RED-S have disordered eating, but it’s important to recognise eating disorders because they can have very serious consequences. So, if there are concerns that low energy availability is due to disordered eating, then this is something the athlete should be encouraged to address before they’re ready to train and compete.

There’s more to it than just RED-S. Lots of athletes experience painful periods or heavy bleeding. It’s often a difficult issue to discuss, so I’d really encourage athletes and coaches to visit websites like health4performance and if necessary, remind their GP that sports medicine exists on the NHS as well as in private practice to help athletes here.

AW: What about the pill and other contraceptives? What influences do they have (good or bad)?

Dr R: There has definitely been a move away from the oral contraceptive pill by gynaecologists working in sport and also by sports medicine doctors. We now know the oral contraceptive doesn’t improve bone density so, usually it isn’t the right option for athletes who aren’t getting their period. Furthermore, the pill masks the body’s own hormones, making it difficult to understand the athlete’s own cycle.

Some athletes struggling with RED-S might be advised to have topical hormone replacement therapy with oestrogen and progesterone to provide a withdrawal bleed, but this should be done by a gynaecologist or sports doctor.

Of course, many people do use the pill and other contraception in real life and this can certainly be a safe option, but it’s always advisable to have medical support.

AW: Should females be concerned about competing at certain times during their cycle, and should they influence their cycle to avoid having heavy periods during competition? I know this is a touchy subject.

Dr R: I definitely agree here. But for some athletes for whom premenstrual tension, pain, or heavy bleeding is an issue, taking a wider look at health is essential and medication can be used with care to manipulate cycles.

For athletes who want to use medication to alter the timing of their period, it’s important to get this right a long way out from major competitions. Some symptoms can be helped through non-medical practices, looking at recovery, fuel and natural anti-inflammatory products.

In sports clinics like CHHP, where I work from, we have a multi-disciplinary team. Getting this right for the athlete can involve sports medicine, nutrition, psychology and physiotherapy, so make sure that you get it right for you and your sport.

The knowledge that every woman can compete well at all times in her cycle informs the ‘FITR’ app that can support menstrual tracking for the sporty female – see fitrwoman.com

AW: Are there supplements and nutritional strategies that may be of benefit?

Dr R: I would recommend the FITR app. It can help athletes to adapt training load to their cycle. At different times of the cycle, we women use different food types as fuel (for example, fat versus carbohydrate), so keeping a diary and getting savvy to this can really help, as can knowing at which times you may best adapt to different types of training. For younger athletes, this is great to learn early on, so that they become the expert on their menstrual health for their sport.

Women who have heavy bleeds need to watch their iron status. Iron is found in meats and green leafy vegetables. Supplements can also help – if in doubt, have your levels checked.

AW: Anything else thought relevant?

Dr R: Research is telling us that athletes who get their period end up stronger, faster and actually get better adaptations to training than those who miss theirs, for reasons such as RED-S (there are other reasons why women might not get their cycle and you can be healthy and on a pill or similar, but if in doubt, check).

I’d encourage young athletes that a healthy menstrual cycle is a sure start to a happier and a longer sports career whatever their goals.

Shortcuts that end in stress fractures and heart-break are also sad for us as sports doctors to manage. Taking the first steps if you think you may need help can turn things around quicker than you think.